Differences Between the Perspectives Of

Liu et al. BMC Health Services Research (2018) 18:961 https://doi.org/10.1186/s12913-018-3783-5

RESEARCHARTICLE Open Access Differences between the perspectives of physicians and patients on the potential barriers to optimal diabetes control in China: a multicenter study Chun Liu1†, Shaoyong Xu1†, Jie Ming1†, Aihua Jia1,2, Yingji Wei3, Hui Li4, Yang Jiao5, Mingxi Song6, Yadong Zhao7, Yafang Du8, Wenjuan Yang9, Xiaoqiang Lu10, Shengqi Shi11, Hui Tong2, Guangtang Jia12, Guohua Zhao13, Li Wang14, Mei Zhang15, Junlin Wang16, Wenshu Liu17, Lin Fang18, Fuhong Dong19 and Qiuhe Ji1*

Abstract Background: To investigate the potential barriers to optimal diabetes control by evaluating the different perspectives of physicians and patients on such matters in China. Methods: This multi-center survey was conducted from December 2015 to March 2016. A multi-stage stratified random sampling method was used to sample representative diabetes physicians and patients in 18 hospitals in Shaanxi province, China. A self-designed questionnaire was used. The questionnaire mainly consisted of 2 questions for physicians and 1 question for patients of which the participants were required to rank in priority of 3 (for physicians) and 2 (for patients) choices from a list of barriers. The strategies to improve diabetes control were only in the questionnaire for physicians. Results: A total of 85 physicians and 584 patients completed the questionnaire. Physicians and patients differed regarding the patients’ awareness of the risk of diabetes: over 70% of the physicians believed that the patients had no sufficient understanding of the harm and risk of diabetes, whereas the patients believed otherwise. Both physicians and patients considered self-monitoring of blood glucose to be an important link of glucose control; unfortunately, most of the patients failed to do so in practice. In addition, physicians considered “improving health insurance coverage for diabetes” as the first important measure and “providing more and easy-to-use diabetes brochures or educational materials for patients” as the second important measure to improve diabetes control. Conclusion: The survey revealed differences between the perspectives of physicians and patients on the potential barriers to optimal diabetes control. The main potential barriers to optimal diabetes control were patient’s poor lifestyle interventions, limited understanding of the danger of diabetes, and poor self-monitoring of blood glucose. From the physicians’ perspective, China’s primary focus about diabetes control in the future should still be put on diabetes education, particular the importance of lifestyle interventions. Keywords: Diabetes control, Barriers, Cross-sectional study, China

* Correspondence: [email protected] †Chun Liu, Shaoyong Xu and Jie Ming contributed equally to this work. 1Department of Endocrinology, Xijing Hospital, Air Force Medical University, 169 Changle Road West, Xi’an 710032, China Full list of author information is available at the end of the article

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Liu et al. BMC Health Services Research (2018) 18:961 Page 2 of 8

Background level city (Yulin, annual Gross National Products GDP > Diabetes prevalence has been increasing dramatically in 50,000 yuan per capita), a moderately developed China in recent years. In 2010, the prevalence rate was prefecture-level city (Baoji, annual GDP 30,000–50,000 11.6% for diabetes and 50.1% for pre-diabetes in adults yuan per capita), and a developing prefecture-level city over 18 in China; the crude prevalence rate was 9.5% for (Ankang, annual GDP < 30,000 yuan per capita) were sam- diabetes and 35.5% for pre-diabetes in Shaanxi province; pled; the GDP was classified according to the 2015 GDP currently, the diabetic patient population in China in Shaanxi Province. This step was non-randomized. Step accounts for approximately one-fourth of the diabetic pa- 2 involved stratifying the hospitals in the capital city and tients worldwide [1]. With the rise in the overall incidence the three prefecture-level cities. The hospitals in the cap- of diabetes and the incidence of diabetes in younger popu- ital city were stratified into medical university hospitals, lations in China, individuals and the society are facing a tertiary municipal hospitals, and secondary county hospi- higher burden of diabetes treatment. Unfortunately, even tals; the hospitals in the prefecture-level cities were strati- with continued innovation in anti-diabetic drugs and con- fied into tertiary municipal hospitals and secondary stantly evolving ideas regarding diabetic treatment, a sub- county hospitals. Step 3 involved sampling the hospitals. stantial increase in expenses for diabetes care has failed to Given the differences in the city sizes and the distribution significantly improve the diabetes control rate; conversely, of medical resources between the capital city and the the morbidity of diabetes has increased each year [2]. prefecture-level cities, we used a simple random sampling Therefore, it is important to investigate the potential bar- (drawing) method to randomly sample three medical uni- riers to optimal diabetes control. versity hospitals, three tertiary municipal hospitals, and Diabetes physicians have gained rich experience in the three secondary county hospitals in the capital city in daily diagnosis and treatment of diabetes, and therefore, addition to one tertiary municipal hospital and two sec- their feedback on the potential barriers to optimal dia- ondary county hospitals in each of the prefecture-level cit- betes control is extremely valuable. Numerous Chinese ies. Thus, we sampled a total of 18 hospitals, including and foreign studies have shown that from the perspec- three medical university hospitals, six tertiary municipal tive of physicians, the patient’s lifestyle [3, 4], mental hospitals, and nine secondary county hospitals. Step 4 in- health [5], economic status [6], and religion [7] have a volved sampling the physicians. According to the distribu- significant effect on diabetes control; furthermore, the tion of physicians in the different levels of the hospitals, physician’s vocational education [8], specialist nurses [9], we randomly sampled six residents, three attending physi- and education [10] also play important roles in diabetes cians, and one chief physician from each medical univer- control. However, the opinions differ between physicians sity hospital; three residents, two attending physicians, in different surveys [3–6]. Notably, few such studies in and one chief physician from each tertiary municipal hos- the past have investigated the potential barriers to opti- pital; and two residents and one attending or chief phys- mal diabetes control from the perspective of patients; ician from each secondary county hospital. Thus, we consequently, an understanding of different perspectives sampled a total of 93 physicians, including 54 residents, between physicians and patients will, undoubtedly, pro- 21 to 31 attending physicians, and nine to 19 chief physi- vide an important reference for improving diabetes con- cians. Step 5 involved sampling the patients. We used the trol and patient compliance in the future. cluster random sampling method and enrolled all of the As such, this multi-center study was designed to inves- patients with type 2 diabetes (based on World Health tigate the potential barriers to optimal diabetes control Organization 1999 criteria) who were hospitalized for dia- by evaluating the different perspectives of physicians and betes treatment in department of endocrine during a cer- patients on such matters, and also investigate the tain time window and who met all of the study criteria, physician-recommended public health measures for im- had poor diabetes control (HbA1c ≥ 7%), and were willing proving diabetes control in China. to participate in this study, until the planned number of participants was reached. Given the difference in ward Methods capacity between the different levels of hospitals, we Study design planned to sample 40 patients in each medical university This multi-center cross-sectional survey was conducted hospital and tertiary municipal hospital and 30 patients in from December 2015 to March 2016. A multi-stage each secondary county hospital, for a total of 630 patients, stratified random sampling method was used to sample which provided a sufficient sample according to previous representative diabetes physicians and patients in literatures [11–23]. Shaanxi province, China for this survey (Fig. 1). Step 1 involved sampling physicians and patients in Data collection the cities. In addition to the capital city (Xi’an), physicians We developed our own questionnaire for data collection. and patients from an economically developed prefecture- While designing the questionnaire, we referred all the Liu et al. BMC Health Services Research (2018) 18:961 Page 3 of 8

Fig. 1 Protocol design flowchart. *: numbers in each hospital barriers and strategies from previous related literatures, Statistical analysis and expanded some potential ones localized for the EpiData software (version 2.3) was used to enter the data Chinese, which were from a small-scale pre-survey obtained into the database, and the Statistical Package [11–23]. Two versions of the survey were used: the phys- for Social Sciences 20.0 (SPSS Inc., Chicago, IL, USA) ician version and the patient version. (Additional file 1). was used for the descriptive statistics. The measurement The physician questionnaire had two parts. Part 1 was data were expressed as the numerical mean and standard used to collect basic information on the physician, in- deviation. Count data are expressed as percentages (%). cluding title and the type and location of the hospital. Part 2 contained two questions. Question 1 asked “Ac- Results cording to your own clinical experience, what do you Physicians questionnaire think are the top three potential barriers to optimal dia- A total of 93 physicians were sampled and asked to par- betes control?” There were three items could be chosen ticipate, of whom 85 agreed to participate and complete from a list of eight items. The physicians were asked to the physician questionnaire (response rate: 91.4%), in- rank the factors in the order of importance. Question 2 cluding 42 (49.4%) residents, 31 (36.5%) attending asked “From the perspective of the government/commu- physicians, and 12 (14.1%) chief physicians; 30 (35.3%) nity/hospital/physician, what do you think are the top physicians were from medical university hospitals, 35 three areas that require urgent improvement in order (41.2%) were from tertiary municipal (non-teaching) hos- to improve diabetes control?” There were three items pitals, and 20 (23.5%) were from secondary county hospi- could be chosen from a list of nine items. Again, the tals; 45 (52.9%) physicians were from the capital city, 24 physicians were asked to rank the areas in the order (28.2%) were from prefecture-level cities, and 16 (18.8%) of importance. were from counties or lower level cities (Table 1). The patient questionnaire contained two parts. Part 1 For question 1 (Figs. 2), “According to your own clin- was used to collect patient demographic data, lifestyle, ical experience, what do you think are the top three po- and history of diabetes. Part 2 contained only one tential barriers to optimal diabetes control?”, 62 (62/85 question: “What do you (the patient) think are the 72.9%) physicians considered patient’s “insufficient un- causes of your uncontrolled blood glucose?” This was derstanding of the danger of diabetes” as an important amulti-choicequestionandthepatientscouldchoose factor, of whom 33 (33/85 38.8%) physicians ranked it as more than one factors for uncontrolled glucose. The the most important factor, 23 (23/85 27.1%) physicians patients were asked to mark the most important item. ranked it as the second most important factor, and 6 See the annex for the questionnaire design and base- (6/85 7.1%) physicians ranked it as the third most im- line information. portant factor. Liu et al. BMC Health Services Research (2018) 18:961 Page 4 of 8

Table 1 Baseline information of the physicians For question 2 (Figs. 3), “From the perspective of the Variable N =85 government/community/hospital/physician, what do you Title, n (%) think are the top three areas that require urgent improve- ” Resident 42 (49.4) ment in order to improve diabetes control? ,38(38/85 44.7%) physicians considered “improving health insurance Attending Physician 31 (36.5) coverage for diabetes” as an important measure, of whom Chief Physician 12 (14.1) 20 (20/85 23.5%) physicians ranked it as the most import- Hospital, n (%) ant factor, 12 (12/85 14.1%) physicians ranked it as the Medical university hospital 30 (35.3) second most important factor, and 6 (6/85 7.1%) physi- Tertiary non-teaching hospital 35 (41.2) cians ranked it as the third most important factor. Secondary hospital 20 (23.5) In addition, 33 (33/85 38.8%) physicians considered “providing more and easy-to-use diabetes brochures or Location, n (%) educational materials for patients” as an important fac- Capital city 45 (52.9) tor, of whom 14 (14/85 16.5%) physicians ranked it as Prefecture-level city 24 (28.2) the most important factor, 12 (12/85 14.1%) physicians County and below 16 (18.8) ranked it as the second most important factor, and 7 (7/ 85 8.2%) physicians ranked it as the third most import- In addition, 56 (56/85 65.9%) physicians considered ant factor. patient’s “lack of perseverance to stick to lifestyle Moreover, although the physicians considered regulat- intervention (if even understanding the danger of ing media campaigns and minimizing false advertising, diabetes)” as an important factor, of whom 29 (29/85 in addition to engaging or encouraging family members 34.1%) physicians ranked it as the most important to become involved in the care of diabetic patients as factor, 21 (21/85 24.7%) physicians ranked it as the important measures for strengthening public health second most important factor, and 6 (6/85 7.1%) management of diabetes, few ranked these factors as the physicians ranked it as the third most important most important factor. Furthermore, the physicians did factor. not consider factors such as strengthening the training Moreover, the physicians considered patient’s failure to of diabetes specialists, training more specialist diabetes monitor blood glucose regularly, poor medication com- nurses to provide guidance for patients, and improving pliance, economic reasons, and the uneducated use of multidisciplinary and multi-specialty collaboration for herbal medicine or health products as moderately effect- diabetes control as urgent public health measures for ive potential barriers to optimal diabetes control. improving diabetes control. Whereas physicians considered factors that failure to at- tend scheduled follow-ups or inconvenience to purchase Patient questionnaire drugs as lower effective factors to diabetes control than A total of 630 patients were sampled and asked to par- other factors. ticipate, of whom 584 patients agreed to participate and

Fig. 2 Potential barriers to optimal diabetes control in physician’s perception Liu et al. BMC Health Services Research (2018) 18:961 Page 5 of 8

Fig. 3 Physician-recommended public health measures for improving diabetes control completed the patient questionnaire (response rate: The data analysis of the 584 valid patient question- 92.70%). Of the patients who completed the question- naires showed that for the question, “What do you (the naire, 325 patients were men with a mean age of 56.27 patient) think are the potential barriers to optimal dia- years (± 13.19), and 254 patients were women with a betes control?” (Figs. 4), 338 (338/584 57.9%) patients mean age of 58.06 years (± 12.79). Moreover, 242 considered “I do not follow a proper diet” as an import- (44.2%) patients had been diagnosed with diabetes for ant barrier, of whom 142 (142/584 24.3%) patients less than 5 years, 175 (32.0%) patients had been diag- ranked it as the most important reason and 196 (196/ nosed with diabetes for 5 to 10 years, and 130 (23.8%) 584 33.6%) patients ranked it as the second most im- patients had been diagnosed with diabetes for ≥10 portant barrier. A total of 263 (263/584 45.0%) patients years (Table 2). considered “I do not exercise as instructed” as an important reason, of whom 55 (55/584 9.4%) patients ranked it as the most important barrier and 208 (208/ Table 2 Baseline information of the patients 584 35.6%) patients ranked it as the second most im- Variable N = 584 portant barrier. Gender, n (%) Moreover, the patients considered failure to monitor Male 325 (56.0) blood glucose as instructed as an important potential Female 254 (43.8) barrier to optimal diabetes control. However, the pa- Mean age, years 57.01 ± 13.27 tients did not consider high drug cost, inconvenience to Male 56.27 ± 13.19 purchase drugs, the use of herbal medicine, and incor- rect treatment protocol as potential barriers to optimal Female 58.06 ± 12.79 diabetes control. Educational level, n (%) Primary school and below 165 (31.3) Discussion Middle and high school 226 (42.9) This multi-center cross-sectional study showed that both College and above 132 (25.0) physicians and patients considered lifestyle as one of the Economic conditiona, n (%) most important potential barriers to optimal diabetes control. However, physicians and patients differed re- Poverty and below 79 (13.5) garding the patients’ awareness of the risk of diabetes: Subsistence level 266 (45.5) over 70% of the physicians believed that the patients had Well-to-do and above 194 (33.2) no sufficient understanding of the harm and risk of Duration of diabetes, n (%) diabetes, whereas the patients believed otherwise. In < 5 years 242 (44.2) addition, this study showed that both physicians and pa- 5 to 10 years 175 (32.0) tients considered self-monitoring of blood glucose to be an important link of glucose control; unfortunately, most ≥ 10 years 130 (23.8) of the patients failed to do so in practice. aEconomic condition was categorized according to per capita annual net income of households: poverty and below < 5000 China Yuan (CNY), subsistence level First, this survey showed that both physicians and pa- 5000–80,000 CNY, and well-to-do and above > 80,000 CNY tients considered lifestyle as one of the most important Liu et al. BMC Health Services Research (2018) 18:961 Page 6 of 8

Fig. 4 Potential barriers to optimal diabetes control in patient’s perception potential barriers to optimal diabetes control. “Lifestyle highlighting basic treatment. Meanwhile, active patient intervention” ranked second in the physician survey, but engagement [10] and effective self-management skills nearly 70% of the physicians considered it an important [14] are important for improving the disease control factor, suggesting that most physicians recognized its im- rate; thus, physicians should encourage and help the portance, which was consistent with survey results in family members of patients become involved in diabetes The United States of America (US) [13], the Middle monitoring and control. East, Thailand and South Africa [6, 15]. The patient sur- Second, physicians and patients differed in the pa- vey showed that nearly 100% of the patients with poor tients’ awareness of the risk of diabetes. Over 70% of the diabetes control checked “I do not follow a proper diet” physicians believed that patients had no sufficient under- or “I do not exercise as instructed” or both, indicating standing of the harm and risk of diabetes, which was that most Chinese diabetic patients recognized the im- consistent with the results in studies conducted in the portance of lifestyle intervention in diabetes control but Middle East, South Korea, and Japan in which physicians did not stick to it [21], which is common in both China believed that patients should learn more about diabetes and other countries [12, 19]. Both physicians and pa- [16–18]. The importance of diabetes education has been tients considered lifestyle intervention an important fac- established in the medical community [14, 21]. However, tor, highlighting its importance in poor diabetes control just under 30% of the patients considered “I do not think in China. In terms of measures for this issue, physicians diabetes is a terrible disease” as an important reason for suggested “providing more and easy-to-use diabetes bro- their poor diabetes control (although this factor ranked chures or educational materials for patients” and “en- third in the patient survey), suggesting that the gaging or encouraging family members to become remaining 70% of the patients may have recognized the involved in the care of diabetic patients”, which differed danger of diabetes. Thus, physicians and patients dif- from the results in some developed countries. For ex- fered in their opinion in this regard. Given the physi- ample, some physicians in the US believed that compre- cian’s professional background in endocrinology, we hensive intervention was more important than providing would place more confidence in the physician’s opinion. more education materials [18] because in developed We believe that most of the patients did not have a suffi- countries, patients already had access to basic health cient understanding of diabetes, which may have im- education and were generally well-informed. Innovation peded diabetes control; moreover, most of the patients in drug research and development and the use of insulin may not have a strong interest in developing a thorough could not substitute for the role of lifestyle interventions understanding of diabetes [18]. Therefore, we conducted in improving diabetes control; conversely, a long-term a supplementary survey in a subgroup of 50 patients poor lifestyle had adverse effects on drug and insulin (Additional file 2). The questionnaire had two parts. Part therapy [20]. Therefore, we suggest that in Shaanxi 1contained basic information. Part 2 contained eight Province, which displays uneven development, priority questions mainly about the diabetes complications should be given to educational diabetes materials (Question2-Question9). Patients got one score when Liu et al. BMC Health Services Research (2018) 18:961 Page 7 of 8

they know one question in part 2. The results showed levels in Shaanxi Province. However, this study had some that among the 41 patients who rated themselves as limitations: Firstly, this study was conducted in only one someone with an understanding of the danger of dia- province, and thus, the results may not be applicable to betes, only 51.2% answered all of the questions correctly, the whole of China. Secondly, the physician’s profes- and 66% answered 75% of the questions correctly. sional skills were unknown, and thus, we were unable to Although the patients who believed themselves to evaluate the effect of physicians’ professional skills on understand the danger of diabetes scored higher (mean uncontrolled glucose. Thirdly, factor on economic rea- score) than those who did not (6.78 vs 4.11, p = 0.028), sons can be many, so the specific factor may not be they had a limited understanding of the acute and available from the results. Fourthly, As the questionnaire chronic complications of diabetes (Additional file 2). only sought physician’s perspective without patients’ per- Thus, based on the measures suggested by the physicians spective for strategies of improvement, hence strategies during the survey, we recommend using more detailed as suggested by physicians may not be actually effective educational materials to improve patient understanding of in improving patient’s diabetes control. Lastly, we only the danger of diabetes. included patients with type 2 diabetes, so the conclusion Moreover, we found that both physicians and patients of this survey may not be generalized to other diabetic (up to 40%) considered self-monitoring of blood glucose population. For example, accessing and maintaining con- as an important link of glucose control; specifically, “fail- tact with diabetes care services may be the most poten- ure to monitor blood glucose regularly” ranked fourth in tial barrier to optimal diabetes control in young patients the physician survey and third in the patient survey as a with type 1 diabetes [24]. factor for poor diabetes control. Economic conditions and (long-term) pain during testing were the two main Conclusions reasons patients cited for failing to monitor their blood This was the first formal large-scale multi-center survey glucose regularly based on our clinical experience. The of diabetes perception in physicians and patients in physicians suggested that health care coverage must first China. The survey revealed differences between the per- be expanded, particularly to cover test strips and needles spectives of physicians and patients on the potential bar- used for glucose monitoring, similar to situations in riers to optimal diabetes control, and the results showed some developing countries [11]. Prof. Weiping Jia that the main potential barriers to optimal diabetes con- (China) has also called on the Chinese government to trol were patient’s poor lifestyle interventions, limited expand health care coverage to cover the costs of glu- understanding of the danger of diabetes, and poor cose monitoring. self-monitoring of blood glucose. Thus, this study sug- In addition, we found that false advertising and certain gests that, as physicians and public health agencies, our herbal medicines and health products were important primary focus about diabetes control in the future potential barriers to optimal diabetes control in Chinese should still be put on diabetes education, particular the diabetic patients, suggesting that patients generally had a importance of lifestyle interventions and the danger poor understanding of diabetes and urgently required of diabetes, by developing and promoting more edu- truthful, accurate, and professional diabetes education. cational materials. In addition, we hope that the The physicians believed that regulating media campaigns Chinese government and society will expand health and eliminating false advertising is one of the four public insurance coverage and take effective measures to health measures necessary to improve the diabetes con- regulate media campaigns. trol rate. Herbal medicines and health products are un- regulated in China, and the abuse of these products Additional files affected glucose control in 10% of the patients based on this survey. In addition, we did not include self- Additional file 1: Survey of the potential barriers to optimal diabetes evaluation items in the physician survey, and therefore, control. (DOCX 30 kb) we were unsure about the effect of iatrogenic events on Additional file 2: Survey of patients’ perspectives for diabetes dangers. patients’ glucose control; however, the patient survey (DOCX 28 kb) showed that iatrogenic events were not a major factor for uncontrolled glucose. Other factors, such as improv- Abbreviations GDP: Gross Domestic Product; HbA1c: HemoglobinA1c; US: The United States ing physician-patient communication, training of spe- of America cialty nurses, and regular follow-ups, were considered important factors for improving glucose control. Acknowledgements The study design was well balanced. Based on the dis- We thank all of the physicians and participants of the study for their co-operation and generous participation. We also thank Prof. Yi Wan, Department of Health tribution of medical resources, we stratified and ran- Statistics, School of Preventive Medicine, Fourth Military Medical University, Xi’an, domly sampled 18 representative hospitals of different China, for the critical reading of this manuscript. Liu et al. BMC Health Services Research (2018) 18:961 Page 8 of 8

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Family doctors’ assessment of patient- manner. and health care system-related factors contributing to non-adherence to diabetes mellitus guidelines. Prim Care Diabetes. 2007;1(2):93–7. Consent for publication 12. Kaltman S, Talisman N, Serrano A, et al. Type 2 diabetes and depression: Not applicable. patient, family member, and primary care provider perspectives on the development of an integrated self-management intervention. Diabetes Educ. 2015;41(6):763–72. Competing interests 13. van den Arend IJ, Rutten GE, Schrijvers GJ, Stolk RP. Experts' opinions on the The authors declare that they have no competing interests. profile of optimal care for patients with diabetes mellitus type 2 in the Netherlands. Neth J Med. 2001;58(6):225–31. Publisher’sNote 14. Strain WD, Cos X, Hirst M, et al. Time to do more: addressing clinical inertia Springer Nature remains neutral with regard to jurisdictional claims in in the management of type 2 diabetes mellitus. Diabetes Res Clin Pract. – published maps and institutional affiliations. 2014;105(3):302 12. 15. Suparee N, McGee P, Khan S, Pinyopasakul W. Life-long battle: perceptions – Author details of type 2 diabetes in Thailand. Chronic Illn. 2015;11(1):56 68. 1Department of Endocrinology, Xijing Hospital, Air Force Medical University, 16. Torres HC, Rozemberg B, Amaral MA, Bodstein RC. Perceptions of primary 169 Changle Road West, Xi’an 710032, China. 2Department of Endocrinology, healthcare professionals towards their role in type 2 diabetes mellitus patient Yulin First Hospital, Yulin 719000, China. 3School of Nursing, Third Military education in Brazil. BMC Public Health. 2010;10:583. Medical University, Chongqing 404100, China. 4Department of 17. Fransen MP, Beune EJ, Baim-Lance AM, et al. Diabetes self-management Endocrinology, Shanxi Provincial Peoples Hospital, Xi’an 710032, China. support for patients with low health literacy: perceptions of patients and – 5Department of Endocrinology, The Second Affiliated Hospital of Xi’an providers. J Diabetes. 2015;7(3):418 25. Jiaotong University, Xi’an 710032, China. 6Department of Endocrinology, The 18. Lee V, McKay T, Ardern CI. Awareness and perception of plant-based diets Fourth Hospital of Xi’an, Xi’an 710032, China. 7Department of Endocrinology, for the treatment and management of type 2 diabetes in a community High-tech Hospital, Xi’an 710032, China. 8Department of Endocrinology, education clinic: a pilot study. J Nutr Metab. 2015;2015:236234. Changan Hospital, Xi’an 710032, China. 9Department of Endocrinology, 19. Gazmararian JA, Ziemer DC, Barnes C. Perception of barriers to self-care – Aerospace Hospital, Xi’an 710032, China. 10Department of Endocrinology, management among diabetic patients. Diabetes Educ. 2009;35(5):778 88. Huxian County People’s Hospital, Xi’an 710032, China. 11Department of 20. Daoud N, Osman A, Hart TA, et al. Self-care management among patients – Endocrinology, Zhouzhi County People’s Hospital, Xi’an 710032, China. with type 2 diabetes in East Jerusalem. Health Educ J. 2015;74(5):603 15. 12Department of Endocrinology, The second people’s Hospital of Shenmu 21. Kamimura A, Christensen N, Myers K, et al. Health and diabetes self-efficacy: county, Yulin 719000, China. 13Department of Endocrinology, Fugu County a study of diabetic and non-diabetic free clinic patients and family members. – Hospital, Yulin 719000, China. 14Department of Endocrinology, Central J Community Health. 2014;39(4):783 91. Hospital of Baoji, Baoji 721000, China. 15Department of Endocrinology, 22. Suraci C, Mulas F, Rossi MC, et al. Management of newly diagnosed patients Qishan County Hospital, Baoji 721000, China. 16Department of Endocrinology, with type 2 diabetes: what are the attitudes of physicians? A SUBITO!AMD Fengxiang County Hospital, Baoji 721000, China. 17Department of survey on the early diabetes treatment in Italy. Acta Diabetol. 2012;49(6): – Endocrinology, Ankang Central Hospital, Ankang 725000, China. 429 33. 18Department of Endocrinology, Xixiang County Hospital, Hanzhong 723000, 23. Adams OP, Carter AO. Diabetes and hypertension guidelines and the primary China. 19Department of Endocrinology, Xunyang County Hospital, Ankang health care practitioner in Barbados: knowledge, attitudes, practices and 725000, China. barriers--a focus group study. BMC Fam Pract. 2010;11:96. 24. Kibbey KJ, Speight J, Wong JL, et al. Diabetes care provision: barriers, Received: 7 April 2018 Accepted: 30 November 2018 enablers and service needs of young adults with type 1 diabetes from a region of social disadvantage. 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